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Data availability The datasets generated and analyzed during the current study, along with the Stata analysis scripts, are openly available in the Figshare repository at [ Abbreviations BMI: Body mass index CI: Confidence interval CVD: Cardiovascular disease GRADE: Grading of Recommendations Assessment, Development and Evaluation HDL-C: High-density lipoprotein cholesterol KD: Ketogenic diet LDL-C: Low-density lipoprotein cholesterol MCID: Minimal clinically important difference NAFLD: Non-alcoholic fatty liver disease PCOS: Polycystic ovary syndrome PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses RCT: Randomized controlled trial REML: Restricted maximum likelihood RoB 2: Risk of Bias 2 (Cochrane tool) SD: Standard deviation SEM: Standard error of the mean TC: Total cholesterol TG: Triglycerides T2DM: Type 2 diabetes mellitus VLCKD: Very-low-carbohydrate ketogenic diet WMD: Weighted mean difference References Zhu H, et al

E-value was calculated to assess the robustness of results to unmeasured confounders

To measure oxygen uptake, 10 min after inorganic phosphate (Pi) 4 mM are added, the mitochondria are treated with palmitoyl-CoA (50 M) and then ADP is added (200 M)

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The choline metabolite TMAO inhibits NETosis and promotes placental development in GDM of humans and mice

This feature allows for carnitine accumulation in cells giving rise to a concentration gradient between intracellular space and blood